Free ForwardHealth Model Plan - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11105 (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

MODEL PLAN: IN-HOME MENTAL HEALTH / SUBSTANCE ABUSE TREATMENT SERVICES
Under s. 49.45(4), Wis. Stats., personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant, processing prior authorization (PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of PA or payment for the service. Name -- Member Birth Date -- Member Member Identification Number Date of This Plan Plan Review Date Name -- Case Manager List family members involved in treatment. 1. 2. 3. 4. 5. 6. List agency team members developing and implementing this plan (include title indicating discipline). 1. 2. 3. 4. 5. 6. 7. 8.

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MODEL PLAN: IN-HOME MENTAL HEALTH / SUBSTANCE ABUSE TREATMENT SERVICES F-11105 (10/08)

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Problem 1

Short-Term Goal (Measurable)

Description of the Problem

Long-Term Goal (Measurable)

Plan (Include the Frequency of Intervention and the Team Member[s] Responsible)

Measurable Results of the Intervention at the Time of Plan Review

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MODEL PLAN: IN-HOME MENTAL HEALTH / SUBSTANCE ABUSE TREATMENT SERVICES F-11105 (10/08)

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Problem 2

Short-Term Goal (Measurable)

Description of the Problem

Long-Term Goal (Measurable)

Plan (Include the Frequency of Intervention and the Team Member[s] Responsible)

Measurable Results of the Intervention at the Time of Plan Review

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MODEL PLAN: IN-HOME MENTAL HEALTH / SUBSTANCE ABUSE TREATMENT SERVICES F-11105 (10/08)

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Problem 3

Short-Term Goal (Measurable)

Description of the Problem

Long-Term Goal (Measurable)

Plan (Include the Frequency of Intervention and the Team Member[s] Responsible)

Measurable Results of the Intervention at the Time of Plan Review

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MODEL PLAN: IN-HOME MENTAL HEALTH / SUBSTANCE ABUSE TREATMENT SERVICES F-11105 (10/08)

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Problem 4

Short-Term Goal (Measurable)

Description of the Problem

Long-Term Goal (Measurable)

Plan (Include the Frequency of Intervention and the Team Member[s] Responsible)

Measurable Results of the Intervention at the Time of Plan Review

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MODEL PLAN: IN-HOME MENTAL HEALTH / SUBSTANCE ABUSE TREATMENT SERVICES F-11105 (10/08)

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Problem 5

Short-Term Goal (Measurable)

Description of the Problem

Long-Term Goal (Measurable)

Plan (Include the Frequency of Intervention and the Team Member[s] Responsible)

Measurable Results of the Intervention at the Time of Plan Review

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MODEL PLAN: IN-HOME MENTAL HEALTH / SUBSTANCE ABUSE TREATMENT SERVICES F-11105 (10/08)

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Program Discharge Criteria

SIGNATURE -- Certified Psychotherapist/Substance Abuse Counselor SIGNATURE -- Psychologist/Psychiatrist * * Either the in-home or multi-agency plan must be signed by a psychologist or psychiatrist.

Date Signed Date Signed

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